Chapter 14: Nursing Care of the Family During Pregnancy

1. Nutrient Needs for Women in Childbearing Years (Preconception)

All Women:

Ideally, women are encouraged to eat a well-balanced diet rich in fresh fruits and vegetables, and low in processed foods and
high sugar foods.

This should occur at every well visit with her Primary Care Provider and her OBGYN. It should also be encouraged at
problem visits if nutrition applies.

This is especially important of women in childbearing years, regardless of contraceptive use.

One specific nutrient of concern is Folate (Vitamin B9). It is important for the nurse to be familiar with foods high in Folate.
If the woman expresses a dislike for Folate rich foods, she can take the supplement form, which is called Folic Acid or foods
that have been fortified with folic acid (Ex: cereals).

Women Without History of Neural Tube Defect in a Child:

Encourage to consume 0.4 mg Folic Acid, and foods high in Folate.

Women With History of Neural Tube Defect in a Child:

At least 1 month before trying to become pregnant, encourage to consume 4 mg of Folic Acid daily, and continuing through
the first trimester of pregnancy.

2. Diagnosis of Pregnancy
Most women suspect pregnancy after a missed menstrual period. Home pregnancy tests are typically done before the woman initiates
prenatal care.

Once pregnancy is confirmed, the pregnancy will be dated to determine her Estimated Date of Confinement (EDC) or due date.
Naegele’s Rule is used to do this if she can tell her the first day of her Last Menstrual Period (LMP).

Example: LMP 4/1/2021. From here, we subtract 3 months (4-3=1, which would be January). Then, we add 7 days (1+7=8),
which will give us the 8th day. Lastly, we may need to add a year. Since the next January will not be in 2021, we will add a
year (2021+1=2022). Her EDC is January 8, 2022.

Signs & Symptoms: (see Moodle Book A&P of Pregnancy for chart on presumptive, probable, and positive signs of pregnancy).

2.1. Childbirth and Perinatal Education

Childbirth education:

Early pregnancy classes that provide fundamental information including

(1) early fetal development

(2) physiologic and emotional changes of pregnancy

(3) human sexuality

(4) the nutritional needs of the mother and fetus.

The classes often address environmental and workplace hazards. Exercises, nutrition, warning signs, drugs, and self-medication are
also topics of interest and concern.
Mid-pregnancy classes

emphasize the woman’s participation in self-management.

Classes provide information on preparation for breastfeeding and formula feeding, infant care, basic hygiene, common
discomforts and simple safe remedies, infant health, parenting, and planning for labor and birth.

Epidural, natural

Medicated/unmedicated

Lay baby on mother/go straight to warmer

Late pregnancy classes

emphasize different methods of coping with labor and birth, and these are often the basis for various prenatal classes.

Because fear of pain in labor is a key issue for many women, childbirth preparation classes provide information on the
management of discomfort during labor and birth and a tour of the birth facility.

Topics include methods to reduce discomfort, such as relaxation and breathing techniques, imagery and visualization, and
biofeedback.

Pharmacologic interventions such as intravenous medications and epidural analgesia are also discussed. Including various
pain management strategies helps couples manage the labor and birth with dignity and greater comfort.

There are also other classes to meet specific learning needs.

These include classes for adolescents,

first-time mothers older than age 35

single women, same-sex couples that may involve a surrogate mother

adoptive parents

parents of multiples

women with special needs such as those with visual or hearing impairments.

In some agencies, classes are also offered in languages other than English.

Refresher classes for parents with children review coping techniques for labor and birth and help couples prepare for sibling reactions
and adjustments to a new baby. Cesarean birth classes are available for couples who have this kind of birth scheduled because of
breech presentation or other risk factors. Other classes focus on vaginal birth after cesarean (VBAC) because many women can
successfully give birth vaginally after previous cesarean birth.

Perinatal care choices:

Birth Plans:

Medicated/Unmedicated

Natural/C-section
Birth setting/provider choices:

CPM/CNM/OBGYN

Free standing birth center/Hospital/Home

Questions to ask when scheduling an appt?

How many deliveries

What are their C-section rates?

Rate of preterm birth? /Complications?

Infections after birth in mother?

Transfer Rate?

The US is the only country where globally the number increases instead of decreases (may be a better way to do things)

3. Adaptations to Pregnancy
Maternal Adaptations:
1. Accepting: This is the first step. It involves adapting her life to the pregnancy. For example: not consuming alcohol. The degree
of acceptance can vary based on her emotional response and if the pregnancy was intended or unintended. Nonacceptance does not
equate rejection, she just may not enjoy the pregnancy experience, but still love the child. Most women can have feelings of
ambivalence. If she is still experiencing ambivalence, especially extremely, during the third trimester, it can indicate unresolved
conflict with the mothering role.

2. Identifying with the Mother Role: How the woman is being mothered as a child is the beginning of this process.

3. Reordering Personal Relationships: Family conflict can occur because of role changes. The nurse should promote effective
communication between the woman and her partner & the woman and her mother. Although the woman's relationship with her
mother is impacted by her acceptance and adaptation to the pregnancy, however, the most important person to have an impact on the
woman is her partner. The relationship between 2 committed people is fluid, meaning that it changes over time. The pregnancy has
the potential to help them grow closer. The woman's sexual desire typically decreases in the first and third trimester, but increases in
the second.

4. Establishing a Relationship with the Fetus:

Phase 1: accepting the pregnancy. Being able to say, "I'm pregnant".

Phase 2: views the growing fetus as distinct from herself. Being able to say, "I'm going to have a baby". Typically occurs in the 5th
month.

Phase 3: She begins preparing for birth and parenting. Being able to say, "I'm going to be a mother".

5. Preparing for Birth: It's normal to have anxieties about birth. Many women will read books, take classes, research, etc.

Partner Adaptations:
1. Accepting the Pregnancy:

Phase 1: Announcement Phase. Acceptance can vary depending on if

the pregnancy was intended, unintended, desired, or unwanted. Ambivalence is common.

Phase 2: Moratorium Phase. Accepting the reality of pregnancy. Men typically become introspective.

Phase 3: Focusing Phase. Negotiating with his partner about his role in labor and preparing for fatherhood. Here, he is identifying as
a father.

2. Identifying with the Paternal Role: This is very individual and based, in part on his experience with his father. Some partners are
motivated and excited, while others are detached and even hostile towards parenthood.
3. Reordering Personal Relationships: The main role here is to nurture and respond to the pregnant woman's feelings and deal with
the reality of pregnancy. Some partners experience rivalry feelings

4. Establishing a Relationship with the Fetus: The partner may rub or kiss the maternal abdomen, talk to the fetus, sing to the fetus,
or interact with the moving fetus on the woman's abdomen.

5. Preparing for Birth: Here he begins putting things together such as the crib, painting, etc. The partner is concerned with
recognizing labor, getting the woman to the facility safely and on time, and have questions about his role during labor and delivery.

Same Sex Couples: Couples that identify as LGTBQ become pregnant in various ways. They experience the same fears, questions,
and concerns as heterosexual couples. Including the partner is important.

Sibling Adaptations: (see box 14.2 on page 269)

1. During the Pregnancy: If possible, bring the child to prenatal visits to be able to hear the heartbeat. If not, the sound can be
recorded and played back. Allowing the child to feel the fetus move, help prepare (decorate, pick clothes), reading books, attending
sibling classes if they are old enough, answer their questions, and bring the child around other babies if possible.

2. At the Hospital: Be ready with open arms when the baby's sibling walks into the room, don't force the baby on the child, help the
child explore and get to know the baby, and give the child a gift from mom/dad.

3. Going Home from the Hospital: Have the child at home with a sitter or grandparent. Have the partner carry in the baby from the car
so that mom can hug the child first.

4. Adjusting at Home with Baby: Make 1:1 time with both parents, include the child with feeding times in fun ways (child can get a
juice when the baby nurses or bottle feeds, child can "feed" a baby doll while mom feeds the baby, or use this time to read aloud to the
child during feeds), praise the child for age appropriate activity so that the child does not view being a baby as "better".

Grandparent Adaptations: Grandparent presence and support can strengthen the family by widening the circle of support and
nurturing. Some grandparents are delighted and eager to help. Some grandparents struggle to identify in their new role, and struggle
with feeling old. Some grandparents react negatively and are non-supportive, which decreases the self-esteem of the new parents.

Momma & their sons, feel they are losing their baby boy once the wife gets pregnant (mom is no longer #1)

Involve the grandparents (allow them to help)

4. Prenatal Care
Regular prenatal visits, ideally beginning soon after the first missed menstrual period, offer opportunities to promote the health of the
expectant mother and her infant.

Prenatal health care enables discovery, diagnosis, and treatment of preexisting maternal disorders and any disorders that develop
during the pregnancy.

The goal of prenatal care is to promote the health and well-being of the pregnant woman, her fetus, the newborn, and the family. It
includes teaching about healthy lifestyle behaviors (Ex: nutrition and physical activity), self-care for common pregnancy discomforts,
and teaching about changes in the mother and growth of the developing fetus.

Routine screening is offered during pregnancy to help identify existing risk factors and potential problems so that efforts to reduce risk
of harm to mother or baby and management of identified conditions can be initiated at the earliest opportunity. 

Prenatal care is also designed to monitor the growth and development of the fetus to identify abnormalities that will interfere with the
course of normal labor and birth.

Prenatal care also provides education and support for maternal self-care and parenting and should include the spouse, partner, or
significant other. 

Traditionally in the USA, providers use the traditional model of care.  In the traditional model of care, the woman's initial prenatal
visit is about 30 minutes, and each subsequent visit is 15 minutes.  Watch this video on the Centering model of care.  

The first trimester lasts from weeks 1 through 13.  The first prenatal visit typically occurs during the first trimester.  The typical
woman will be seen every 4 weeks during the first trimester by both the traditional model and the centering model.

The initial prenatal visit is the longest scheduled visit for the traditional model and the centering model because there is a lot of
information to be gathered such as:
Intake Form

Physical Form

laboratory test

diet teaching

avoid raw foods

deli meats

fish with mercury

stinky cheeses (only pasteurized)

shop perimeter of grocery store

safe med list

plans to breast/bottle feed

parenting skills class if needed

adolescent

older pregnant women (>35yo)

Hx of drug use

seatbelt safety

lab across the hipbone

shoulder above the bump

review of systems

uterus (cramping or bleeding contraction)

breast (tender, pain, leakage)

skin (itching)

Muscle (

GI (N/V)

Heart/Resp (SOB

Renal (frequency, smell, odor, color)

Endocrine (

Immune (fever, body ache, feeling run down)

risk identification

DM (type I/II)

Hypertension

Obese

Mental health disorders

Hx of GDM

Clotting disorder

 Reproductive History
 Health & Family History
 Nutritional History 
 History of Medications (include Herbals)
 Mental Health Screening
 Intimate Partner Violence (IPV screening)
 Desire to breastfeed or bottle feed (this can change, but typically women know which they would like to do before
pregnancy)
 Use of BMI to educate regarding expected weight gain

Underweight pre-pregnancy BMI/Singleton Pregnancy Weight Gain Recommendations: (28-40 lbs. total)

Normal pre-pregnancy BMI/Singleton Pregnancy Caloric Intake & Weight Gain Recommendations : (25-35 lbs. total)

 First Trimester: 1800 kcal/day.  The woman may lose weight in the first trimester related to N/V.  
 Second Trimester: 2200 kcal/day and 0.8–1 lb./week
 Third Trimester: 2400 kcal/day and 0.8–1 lb./week
Overweight pre-pregnancy BMI/Singleton Pregnancy Weight Gain Recommendations: (15-25 lbs. total)

Obese pre-pregnancy BMI/Singleton Pregnancy Weight Gain Recommendations: (11-20 lbs. total)

The initial prenatal visit is the time where we date the pregnancy (this determines how many weeks pregnant the woman is).  Once we
establish that her cycles are regular, we can use the first date of her last menstrual period (LMP) and use Negele’s Rule.  Naegele’s
Rule is a simple formula where you take the LMP and subtract 3 months, add 7 days, add 1 year.  For example, if the first date of her
LMP is 12/1/2020 ---> 12-3=9 (September), 1+7=8 (day), 2020+1= 2021 (year) so her due date (also called Estimated Date of
Confinement, EDC) would be September 8, 2021.  This is confirmed by ultrasound and the physical exam.  If at her initial visit (in
January of 2021) she gives a LMP of 12/1/2020, but you palpate a uterine fundus at the umbilicus and are able to obtain fetal heart
tones (FHT) over the abdomen, what would this lead you to think?

Follow-up visits are less comprehensive than the initial visit.  

Subjective and objective assessments are made.  

Subjectively, asking about improvements in complaints from previous visits

new questions or concerns,

presence/absence of danger signs

bleeding, leakage of fluid, abd pain & tenderness, shoulder pain-infection in uterus

new experiences

mood swings

body image, worries, and partner/family support.  

Other questions will be asked based on gestation such as

if the woman intends to attend breastfeeding classes or childbirth classes

 has a car seat, or has a crib.  

The nurse will also ask about self-care measures taken for discomforts of pregnancy.  

Subjective questions should also be asked related to fetal assessment.  

These questions will be based on gestational age.  

We want to look at trend of weight vital signs (everything) from preconception-birth

Once the woman begins feeling fetal movement, asking about kick counts at every visit will occur.  

Objective assessment of the woman includes:

weight, blood pressure, heart rate, edema

abdominal inspection/palpation

fundal height (once she is 20 weeks or greater)

FHT (beginning late in the 1st trimester)

urine (depending on the OB practice)

labs/ultrasound depending on need or gestational age.

The second trimester from weeks 14 through 26.  

The typical woman will be seen every 4 weeks during the second trimester by both the traditional model and the centering
model.

The second trimester is when the woman receives her second routine ultrasound at 20 weeks.  

This ultrasound is looking at the fetal anatomy and wellbeing.

The third trimester from weeks 27 through 40.  

The typical woman will be seen every 2 weeks from week 28-36 by both the traditional model.  

Beyond week 36, she will be seen weekly by the traditional model.  

If the centering model is used, the woman will typically be seen every 2 weeks from week 28-40 weeks.

4.1. Routine Lab Tests During Pregnancy

Although not included on Table 14.1, a clean-catch urine specimen is obtained to test for dipstick glucose, protein, nitrites, and
leukocytes at each visit.

Table 14.1 but I've added hyperlinks.  Click on the links for more information on that topic.
Laboratory Tests in the Prenatal Period

Laboratory Test Purpose

Detects anemia and infection

Hemoglobin, hematocrit, WBCs, differential

Hemoglobin electrophoresis Identifies women with hemoglobinopathies (e.g., sickle cell anemia,
thalassemia)

Blood type, Rh, and irregular antibody

Identifies women whose fetuses are at risk for developing erythroblastosis
fetalis or hyperbilirubinemia in the neonatal period

Rubella titer Determines immunity to rubella

Screens for exposure to tuberculosis

Tuberculin skin testing; chest film after 20 weeks of
gestation in women with reactive tuberculin tests

Identifies women with glycosuria, renal disease, hypertensive disease of

Urinalysis, including microscopic examination of
pregnancy; infection; occult hematuria; hCG for confirmation of pregnancy
urinary sediment; pH, specific gravity, color, glucose,
albumin, protein, RBCs, WBCs, casts, acetone; hCG

Urine culture Identifies women with asymptomatic bacteriuria

Renal function tests: BUN, creatinine, electrolytes, Evaluates level of possible renal compromise in women with a history of
creatinine clearance, total protein excretion diabetes, hypertension, or renal disease

Pap test Screens for cervical intraepithelial neoplasia; if a liquid-based test is used,
may also screen for HPV

Screens for asymptomatic infection at first visit

Cervical cultures for gonorrhea and chlamydia

Vaginal/anal culture (Group Beta Strep) GBS test done at 35–37 weeks for infection

Syphillis with either the RPR, VDRL, or FTA-ABS Identifies women with untreated syphilis, done at first visit

HIV antibody, hepatitis B surface antigen, Screens for the specific infections
toxoplasmosis

1-h glucose tolerance Screens for gestational diabetes; done at initial visit for women with risk
Laboratory Tests in the Prenatal Period

Laboratory Test Purpose

factors; done at 24-28 weeks for pregnant women at risk whose initial screen
was negative and for others who were not previously tested

3-h glucose tolerance

Tests for gestational diabetes in women with elevated glucose level after 1-h
test; must have two elevated readings for diagnosis

Cardiac evaluation: ECG, chest x-ray, and Evaluates cardiac function in women with a history of hypertension or
echocardiogram cardiac disease
4.2. Routine Screening
During pregnancy all women should be offered screening tests for chromosomal abnormalities based on factors such as age, previous
obstetric history, family history, gestational age when prenatal care began, number of fetuses, availability of testing, and the desire for
early results.  

First trimester screening is typically done between 11-14 weeks.  To do this, a sample of blood is taken from the woman and
biochemical markers are examined to determine fetal risk of aneuploidy (Ex Trisomy 21).  The woman may also be offered cell-free
DNA (cfDNA) testing.  This can be done as early as 10 weeks.  It screens for common trisomies, and can also identify fetal sex
chromosomes.

Second trimester screening can be used in conjunction with the results of first trimester screening to increase the accuracy of results. 
This is a variation seen in care.  Some providers will offer only first trimester screening, and others will offer both. Screening for
neural tube defects and other open fetal defects in the second trimester is done by measuring the maternal serum AFP (MSAFP) level
and by ultrasonography. False-positive results are common and warrant further testing with amniocentesis. If the woman initiates
prenatal care in the second trimester, the screening that she will be offered is called the quadruple screen.  The quadruple screen will
be offered in conjunction with cfDNA and a fetal ultrasound exam.

**Note: This section is discussing screening, which is not diagnostic.  That is why we use amniocentesis to confirm because it is
diagnostic.

4.3. Routine Ultrasounds During Pregnancy

In the first trimester ultrasound is used to:

 Confirm pregnancy
 Confirm viability
 Determine gestational age
 Rule out ectopic pregnancy
 Detect multiple gestation
 Determine cause of vaginal bleeding
 Visualization during chorionic villus sampling
 Detect maternal abnormalities such as bicornuate uterus, ovarian cysts, fibroids
In the second trimester ultrasound is used to:

 Establish or confirm dates

 Confirm viability
 Detect congenital anomalies (this is the 20 week anatomy scan)
 Assess fetal growth
 Assess placental location
 Visualization during amniocentesis if it is being done
In the third trimester ultrasound is used to:

 Confirm gestational age if needed

 Confirm viability
 Detect problems
 Fetal growth
 Determine fetal position if necessary
 Visualization during amniocentesis, external version if either are being done
 Biophysical profile (this is essentially the closest thing to a head-to-toe exam on the baby)
4.4. Routine OB Appointment
We have established that spread throughout the pregnancy there will be labs and ultrasounds, but there are evaluations of both mother
and fetus done at every appointment.

Routine Maternal Screening: 

 Weight
 Blood Pressure
 Urine
 Diet
 Adverse s/s.  The adverse s/s will be specific to where she is in the pregnancy and her health status (lack of/presence of
cardiovascular disease, renal disease, diabetes).  
Routine Fetal Screening:

 Fundal height.  Fundal height is palpated only and not measured with a measuring tape until weeks 18-20.
 FHT once the uterus becomes an abdominal organ.
 Fetal movement.  This is called "kick counts" and is something done by the mother and reported to the clinician.  Kick counts
begin once the mother can regularly feel fetal movements.  For primiparas, this is typically around 18-20 weeks.  For
multiparas, it typically occurs sooner.  Several different protocols are used for counting. One recommendation is to count
once a day for 60 minutes. Other common recommendations are that mothers count fetal activity two or three times daily
(after meals or before bedtime) for 2 hours or until 10 movements are counted, or all fetal movements in a 12-hour period
each day until a minimum of 10 movements are counted.
4.5. Routine Teaching
Initial Appointment: very teaching heavy (longest appt)

 Activity & exercise

 Diet 
 Hot Temperature (avoidance of hot tubs and very hot baths)
 Dental care
 Preventing UTIs
 Kegel exercises
 Personal hygiene
 Education: include the family if possible.  It can be confusing to the woman to hear conflicting information from the
healthcare team and family/friends.  Education is ongoing and not limited to the initial appointment.  It should include
expected maternal and fetal changes related to her point in the pregnancy.
First Trimester: 

 Healthy diet
 Severe vomiting: some women experience hyperemesis gravidarum.  How to stay hydrated.
 Symptoms of infection: chills, fever, burning on urination, diarrhea.  
 Signs of miscarriage or ectopic pregnancy (AKA Danger Signs): abdominal cramping and/or vaginal bleeding
 Leukorrhea of pregnancy
Second and Third Trimester:

 Healthy diet
 Do not lie completely supine.
 Posture and Body Mechanics.  The hormone relaxin causes joints to soften and relax, which places stress on the supporting
muscles.  See figure 14.9 on page 280.
 Rest and Relaxation.  Side lying is recommended to promote uterine perfusion and fetoplacental oxygenation which can lead
to supine hypotension.  See figure 14.10, 14.11, and 14.12 on page 281.  
 Persistent severe vomiting: sometimes vomiting lasts beyond the first trimester.  This could be a symptom of hyperemesis
gravidarum, hypertension, or preeclampsia.  (You will cover hypertension and preeclampsia in pregnancy later).
 Pre-labor Premature Rupture of Membranes (PPROM): sudden discharge of fluid before 37 weeks. This can be a large gush
or a trickle.  
 Signs of a problem with the pregnancy or placenta: vaginal bleeding and/or severe sudden abdominal pain
 Signs of infection: chills, fever, burning on urination, severe back/flank pain
 Signs of preterm labor: contractions, cramping, pelvic pressure, severe back pain before 37 weeks
 Fetal distress: change in fetal movements--absence of fetal movements after quickening, any unusual change in pattern or
amount of fetal movements.
 Danger Signs: vaginal bleeding, leaking, visual changes (blurred vision, double vision, or spots in vision), swelling of
face/fingers/sacrum, headaches that are severe/frequent/continuous, muscular irritability or seizures, epigastric pain, or
abdominal pain.
4.6. More Nursing Teaching
Clothing: Dress for comfort.  

Maternity bras provide support for the increased breast weight.  

Support hose help improve venous return, and should be put on first thing in the morning before getting out of bed.  

High heels should be avoided because of joint relaxation.

Medications/Herbals: At the initial prenatal visit, she should be given a list of "ok" medications and supplements.  All others should
be avoided unless discussed with the provider.

Travel: Seat belts should be worn properly with both lap belt and shoulder restraint.  The lap belt should be placed low on her
abdomen, as close to her pelvis as possible.  The shoulder restraint should sit above the gravid abdomen.  Travel should be avoided to
areas where there is limited or poor health care, there is untreated water, or the area is prevalent in Zika, Malaria, or COVID.  Some
travel vaccines are contraindicated in pregnancy such as the Tb vaccine.  Travel should be limited to 8 hours/day because of the risk
for DVT, and 10 minute walk breaks should be taken every 2 hours and use of compression stockings is advised.  While the woman is
sitting, she should be doing leg motions such as foot circling.  

Immunizations: Live attenuated vaccines are not given in pregnancy.  Recommended vaccines during pregnancy include: Tdap (27-
36 weeks) with every pregnancy, Influenza vaccine if seasonal (intranasal is contraindicated because it is live), and COVID.

Rh Immune Globulin: If the woman is Rh negative (D-), she will have an antibody screen in the 1st and 3rd trimesters.  This is
because is the fetus is Rh positive (D+), the fetus can develop antibodies against the D antigen on the fetal red blood cell.  This causes
lysis of the fetal red blood cell, which can lead to life threatening hemolytic disease of the fetus and newborn.  The woman will
receive Rh immune globulin (Rhogam) to prevent formation of antibodies.  

Substance Use: Any drug or environmental agent that enters the woman's blood stream, has potential to cross the placenta and harm
the fetus.  The nurse should screen for substance use at each visit.  Screening can involve asking or testing the woman's blood or urine.
Daily Fetal Movement Kick Count: Once the woman begins feeling fetal movements beyond quickening, she will be instructed to
monitor the fetal wellbeing by performing Kick Counts. 

Monitoring fetal movements is an inexpensive, non-invasive, and simple to task for the woman to perform to monitor fetal
wellbeing.  The presence of movements is considered reassuring. 

There are several accepted methods to teach the woman how to perform kick counts.  

One recommendation is to count once a day for 60 minutes.

She can also count fetal activity two or three times daily (ex: after meals or before bedtime) for 2 hours or until 10
movements are counted, or all fetal movements in a 12-hour period each day until a minimum of 10 movements are
counted.

Smart phone apps (Ex: Baby Kicks Monitor and Count the Kicks) are also available for recording fetal movements. 

Except for establishing a very low number of daily fetal movements or a trend toward decreased motion, the clinical
value of the absolute number of fetal movements has not been established, other than in the situation in which fetal
movements cease entirely for 12 hours (the so-called fetal alarm signal).

A count of fewer than 3 fetal movements within 1 hour warrants further evaluation by a nonstress test (NST) or a
contraction stress test (CST) and a complete or modified biophysical profile (BPP). (NST and CST are going to be
discussed in High Risk Antepartum). 

Women should be taught the significance of the presence or absence of fetal movements, the procedure for counting, how to
record findings on a daily fetal movement record, and when to notify the health care provider.

Toxoplasmosis(protozoa): Most infections are asymptomatic.  

Acute infection is similar to mononucleosis. 

The woman's immune after first episode (except in immunocompromised clients).  

Congenital infection is most likely to occur when maternal infection develops during the third trimester.

The risk of fetal injury, however, is greatest when maternal infection occurs during the first trimester.  

 Counseling: Prevention, Identification, and Management 

1. Good handwashing technique should be used.
2. Eating raw or rare meat and exposure to litter used by infected cats should be avoided; Toxoplasma titer should be checked if
there are cats in the house.  The woman should be instructed delegate emptying the litter box, if at all possible, to avoid
possible exposure.
3. If titer is rising during early pregnancy, therapeutic abortion may be considered an option
5. Variations in Prenatal Care
Many cultural variations are found in prenatal care.  

Unless the cultural practice is causing harm there is no need to correct, let them do it their way

Because pregnancy is considered a normal process and the woman is in a state of good health, many cultural groups regard care
from a healthcare professional only necessary during illness.  

Cultural prescriptions tell the woman what to do.  

Cultural proscription is the established taboos.  

 Variations include:

 Emotional Response: almost all cultures value maintaining a peaceful and agreeable environment for the pregnant woman.  
 Physical Activity/Rest: Some cultures encourage the woman to continue with routine daily life with the exception of nothing
strenuous.  Other cultures believe that inactivity protects the mother and child.
 Clothing: Modesty is the most common expectation among cultures.  Some require amulets or beads for protection.
 Sexual Activity: In most cultures, sex is not prohibited until the end of the pregnancy.  Some cultures forbid sex during
pregnancy.
 Diet: some cultures have specific food preparation rules, some omit meats, and others only allow for the woman to consume
warm foods.
Age impacts how the couple responds to the physical and psychosocial adaptions to pregnancy.

 Adolescents: numerous pregnancy-prevention programs have had varying degrees of success.  

o The programs that make a difference are programs that have a commitment to the adolescent over a long period of
time, involve the parents and other community adults, promote abstinence and personal responsibility, and help the
adolescent with goal setting and planning (such as college).  
o Adolescents are less likely to seek prenatal care and more likely to smoke (which leads to low/very low birth weight
infants).  
o They also have higher incidence of infant death, incidence of anemia, preterm birth, pregnancy complications
(preeclampsia, HELLP, postpartum hemorrhage, chorioamnionitis).  
o However, they do not have a higher incidence of c-sections.
 Women older than 35: These women are considered advanced maternal age (AMA).  
o The older the woman is, the more likely she is to have a preexisting condition such as hypertension.  
o AMA women are more likely to experience: miscarriage, stillbirth, fetus with chromosomal abnormality, DM, HTN,
placenta Previa, placental abruption, c-sections, and a higher pregnancy-related mortality.
 More at risk to miscarry due to genetic anomaly risk